1. EndoVenous Laser Ablation DR WALID ASAAD MBBS,MD,DABR ASS. PROF
EndoVenous Laser Ablation DR WALID ASAAD MBBS,MD,DABR ASS. PROF. DIAGNOSTIC &INTERVENTIONAL RADIOLOGY KING ABDULAZIZ UNIVERSITY HOSPITAL

2. Definition
Telangiectasias - are a confluence of dilated intradermal venules less than one millimeter in diameter.
Reticular veins - are dilated bluish subdermal veins, one to three millimeters in diameter. Usually tortuous.
Varicose veins - are subcutaneous dilated veins three millimeters or greater in size. They may involve the saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.

3. Abnormal Veins
Telangiectasias
Varicose vein
Reticular veins

4. Common Questions Are they dangerous? How do they form?
Why does it happen?
Did I inherit it?
What tests can we use?
What treatments are available?

5. Superficial veins
Great saphenous – formed by the union of the dorsal digital vein of the great toe and the dorsal venous arch.
Ascends anterior to the medial malleolus, posterior to the medial condyle of the femur. It freely communicates with the small saphenous vein.
Proximally it traverses the saphenous opening in the fascia to enter the femoral vein.

6. Small saphenous vein
Formed by the union of the dorsal digital vein of the 5th digit and distal venous arch.
Runs posterior to the lateral malleolus, lateral to the calcaneal tendon.
Runs superiorly medial to the fibula and penetrates the deep fascia of the popliteal fossa, ascends between the heads of the gastrocnemius muscle to join the popliteal vein.

7. Perforating veins
Penetrate the deep fascia, tributaries of the saphenous veins, valves are located just distal to penetration of the deep fascia.
Veins cross the deep fascia obliquely
Muscle contraction causes the valves to close prior to venous compression so blood is forced proximally (musculo-venous pump).

8. Deep Veins
Usually paired with named arteries inside a vascular sheath, this allows arterial pulsation to force blood proximally.
The popliteal vein joins the femoral vein in the popliteal fossa
Femoral vein is joined by the deep vein of the thigh. The femoral vein passes deep to the inguinal ligament to become the external iliac vein.

9. Etiology Reflux 80% Venous obstruction 18-28% Muscle Pump Dysfunction
Resultant edema and skin changes = Postthrombotic syndrome
Muscle Pump Dysfunction

10. Stasis Pathophysiology
Usually associated with venous incompetence
Primary and secondary reflux
Edema
Vein wall dilatation
Inflammation/Pigmentation (Hemosiderin deposits)
“Fibrin cuffing”
Ulceration

11. Risk factors
Age: Aging causes wear and tear. Eventually, that wear causes the valves to malfunction.
Sex: Women > Men. Hormonal changes during pregnancy or menopause. Progesterone relaxes venous walls. OCP may increase the risk of varicose veins.
Genetics
Obesity: Increases venous HTN.
Standing for long periods of time. Prolonged immobile standing impairs venous return.

12. Strong familial component
Not well studied
Twin studies 75% identical, 52% non identical
If both parents VVS - 90% of children VVs
If one parent was affected 25 percent for men and 62 percent for women

13. Symptoms
Achy or heavy feeling, burning, throbbing, muscle cramping and swelling.
Prolonged sitting or standing tends to intensify symptoms.
Pruritis
Painful skin ulcers

14. Complications
Extremely painful ulcers may form on the skin near varicose veins, particularly near the ankles.
Brownish pigmentation usually precedes the development of an ulcer.
Occasionally, veins deep become enlarged.
Bleeding
Superficial thrombophlebitis

15. Indications for EVLT or RFA: lessons from the American Venous Forum February of 1994 and the creation of CEAP
Clinical C0: No visible or palpable signs of venous disease C1: telangiectases or reticular veins C2: varicose veins C3: edema C4: skin changes ascribed to venous disease a. pigmentation or eczema b. lipodermatosclerosis or atrophie blanche C5: skin changes as defined previously with healed ulcer C6: skin changes as defined previously with active ulcer Etiologic: congenital, primary, secondary or none Anatomic: superficial, perforator, deep or none Pathophysiologic: reflux, obstruction, both or none
Most Common

16. Patient Assessment History Examination Trendelenburg Test
History of symptoms and onset
History of venous complications
Desire for treatment
Comorbidities
Rule out secondary cause including DVT and HEART Failure
Examination
Patient in general
Pedal pulses
Groins
Veins
Trendelenburg Test
Venous claudication

17. Investigation All get a Duplex scan Examines – Deep veins
– Superficial veins
– Incompetence and patency
Other Tests
Physiologic testing
Phlebography
Intravascular Ultrasound

18. Duplex scan Vast majority have superficial incompetence only.
Sensitivity 95 % for identifying the competence of the saphenofemoral and saphenopopliteal junctions.
Less sensitive for identifying incompetent perforators (40 to 60 percent) .

19. Treatment Conservative Leg elevation Exercise Compression stockings
Treatment of other underlying conditions
Nothing

20. Vein ablation therapies
Classified by method of vein destruction:
1. Chemical (sclerotherapy)
2. Thermal (laser or endovenous ablation)
3. Mechanical (surgical excision or stripping)

21. Who gets sclerotherapy
Small non-saphenous varicose veins (less than 5 mm),
Perforator veins
Residual or recurrent varicosities following surgery
Telangiectasia
Reticular veins

22. Who gets Sclerotherapy
Who else
– Good control with Trendelenburg
– Recurrent veins
– Frail with resistant/healed ulcers

23. Sclerosing Agents Sodium tetradecyl sulfate Hypertonic Saline
Polidocanol
Monoethanolamine oleate
Glucose combinations
Damage endothelium leading to thrombosis of the vein.
Pressure to try and reduce the amount of thrombus.

24. Microsclerotherapy 30 g butterfly needle 0.2% STD
Several courses required
benefit compression

25. Telangiectasias

26. Foam Sclerotherapy 1:4 Sclerosant (1% or 3%): Air Why foam?
– Induces spasm
– Disperses further
– Enhanced sclerosis
Breu, FX, Guggenbichler, S. European Consensus Meeting on Foam Sclerotherapy, April, 4-6, 2003, Tegernsee, Germany. Dermatol Surg 2004; 30:709.

28. Spider veins

29. Foam Sclerotherapy: Complications
Phlebitis
Skin staining
Failure
Residual lumps
Matting
Embolus (CVA)
DVT
Ulceration (rare)
Anaphylaxis (very rare)

30. Foam Sclerotherapy Results
Variable depending on series
Long-term recurrence rates are as high as 65 percent in five years, however, patients can also be retreated when veins recur
Large veins can be a problem
Currently randomized trial

31. Catheter-based Treatments
Endovenous laser EVLA
Radiofrequency ablation RFA
Primarily to treat saphenous insufficiency (great or small)
EVLA and RFA, are equally efficacious & have similar recanalization rates.
Boros, MJ, O'Brien, SP, McLaren, JT, Collins, JT. High ligation of the saphenofemoral junction in endovenous obliteration of varicose veins. Vasc Endovascular Surg 2008; 42:235.

32. Radiofrequency ablation
Radiofrequency ablation devices (ClosureFast™, RFiTT®, ClosureRFS™) generate a high frequency alternating current in the radio range of frequency.

33. Mechanism RFA
- By directing resistive radiofrequency energy through a vein, a narrow rim of tissue less than 1mm is heated by an electrode.
- The amount of heating is modulated using both a microprocessor and manual movement, resulting in controlled collagen contraction, thermocoagulation and absorption of the vein.

34. Endoluminal radiofrequency ablation of the great saphenous vein: methods
Percutaneous access to the greater saphenous vein most commonly at the level of the knee under duplex ultrasound guidance
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON LAPROSCOPIST & COLOPROCTOLOGIST

35. Endoluminal radiofrequency ablation of the great saphenous vein: methods
1) A guidewire is advanced to the SF junction over which the closure catheter is passed 2) catheter prongs are extruded to contact the intimal lining of the vessel wall 3) radiofrequency generator allows the tip of the catheter and the prongs to attain a temperature of 85 degrees C.

36. Varicose veins

37. Endovenous Laser

38. Endovenous Laser Devices (EVLT®, ClosurePlus™)
Use a bare tipped optical fiber which applies laser light energy to the vein.
Therapy based on photothermolysis (light induced thermal damage).
Laser light heats the target tissue inducing thermal injury
Wavelength of light is chosen based on the target structure's chromophore.
Bush, RG, Shamma, HN, Hammond, K. Histological changes occurring after endoluminal ablation with two diode lasers (940 and 1319 nm) from acute changes to 4 months. Lasers Surg Med 2008; 40:676.

39. Endovenous laser therapy (EVLT): mechanism
- Thermal reaction after laser exposure is essential.
- Damages endothelial, intimal internal elastic lamina, and to some degree the media. Adventitia is rarely affected.
- In vitro studies suggest that energy results in ‘boiling of blood’ and generation of ‘steam bubbles’ that indirectly, homogenously affect the varicose vein.

40. Endovenous laser therapy: methods
1) GSV entered at the knee 2) Guidewire passed through hollow needle into the vein can be difficult if: a. tortuosities b. local venous spasm c. sclerotic fragments 3) Needle removed 4) 3mm cutaneous incision made 5) Introducer sheath placed over guide wire 6) Guidewire removed when at the SFJ 7) Longitudinal US visualization of sheath 1-2 cm distally to the SFJ

41. Endovenous laser therapy and radiofrequency: methods
Tumescent anesthesia (5 ml epi, 5 ml bicarb, 35ml 1% lidocaine in 500ml saline) is administered to the perivenous space resulting in a) reduction in pain
b) protection of perivenous tissue through cooling c) increase in surface area of laser tip
and vein wall

42. Wavelengths of light used for venous laser therapy
Mozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg 2005; 41:130.

43. Endovenous laser therapy and radiofrequency: specifics
Pulsed vs. continuous: pulsed mode is associated with higher adverse events Wavelengths: Higher wavelengths (1320nm) reported less postoperative pain, and less likely to have ecchymoses Fluence (J/ cm2): Single most important parameter to quantify above J/ cm2 for durable GSV occlusion Wattage: high, short duration wattage vaporizing effect low prolonged wattage coagulating effect Pullback Speed: if performed at fixed wattage then energy is
solely dependent on pullback speed

44. Surface laser therapy
Telangiectasias, reticular veins and small varicose veins <5mm
Not used for larger varicose veins

45. Post op care
Graduated compression stockings are worn following the procedure.
F/U duplex ultrasound is performed within one week to evaluate for thrombus in the common femoral vein.
Pt recovery averages two and four days
Significantly shorter interval than is seen with surgical ligation and stripping

46. Endovenous complications
Pain, bruising, hematoma
Skin changes: burns, induration, pigmentation, matting, dysesthesia, & superficial thrombophlebitis.
Nerve injury
DVT
Wound infection
Mozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg 2005; 41:130.
VAN DEN Bos, RR, Neumann, M, DE Roos, SP, Nijsten, T. Endovenous laser ablation-induced complications: Review of the literature and new cases. Dermatol Surg 2009;

47. Which is Better ???
Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-analysis of recurrence of reflux.
ES Xenos, G Bietz, DJ Minion, et al

48. Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-analysis of recurrence of reflux.
Method: Systematic search of Medline/Pubmed, OVID, EMBASE, CINAHL, Clinicaltrials.gov and Cochrane central register
in all lanuages

49. Method Randomized prospective clinical trials with > 365 days f/u.
Analyzed outcomes included recurrence of varicosities and reflux, as documented by duplex ultrasound, and recurrence of signs and symptoms

50. Results 8 randomized controlled trials were included
497 patients total
226 L/S
271 endoluminal thermal ablation
F/U 584 SD182 days.

51. Conclusion
Catheter-based treatments and traditional venous stripping with high ligation have similar long-term results
Catheter-based treatments have a decreased post op pain, shorter recovery time to work and normal activity.